Download A-A Pacemaker Patient Information Booklet.indd

Pacemaker
patient information
Working together to improve the diagnosis, treatment
and quality of life for all those affected by arrhythmias
www.heartrhythmalliance.org
Registered Charity No. 1107496
Glossary
Atria The two upper chambers of the heart
Contents
AV node Part of the electrical pathway between the
atria and the ventricles
The heart during
normal rhythm
Electrocardiogram (ECG) Records the electrical
activity within the heart
What is a pacemaker?
Ventricles The two lower chambers of the heart,
providing most of the pumping force
Heart block Electrical impulses are slowed or
blocked as they travel from the top to the bottom
chambers of the heart
Why do I need a
pacemaker?
How is the
pacemaker
implanted?
What happens after
the pacemaker is
fitted?
Is there any
equipment that
can affect my
pacemaker?
Monitoring devices
Important information
This booklet is intended for use by people who
wish to understand more about pacemakers.
The information comes from research and
previous patient experiences and offers an
explanation of the pacemaker procedure.
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The heart during normal rhythm
If your doctor has suggested that you have a
pacemaker fitted, it is because you have an
abnormality in the electrical conduction system of
your heart. To help you understand this, it may be
useful for you to know how the electrical conduction
system in your heart works normally.
The heart is a muscle; its function is to pump blood
and oxygen around your body to all of your vital
organs. A normal healthy heart usually beats in a
regular fashion at around 50 to 100 times a minute.
The heart and
normal conduction
Pulmonary veins
Sinus
node
Atrium
AV node
It has four chambers, two at the top (the right and
Conducting
left atria) and two at the bottom (the right and left pathways
ventricles). The heart also has an electrical system,
Ventricle
which sends impulses through the heart causing it
© 2012 Arrhythmia Alliance
to contract and pump blood around the body.
Each normal heartbeat begins in the natural
pacemaker of the heart (the sino-atrial or SA node),
which lies at the top of the right atrium. It then
travels across the two top chambers and down
through a small junction box (the atrio-ventricular or
AV node), which lies between the upper and lower
chambers. It then spreads rapidly through a special
conducting system through the ventricles causing
the heart to contract and pump.
Sometimes the electrical system in your heart does
not work as well as it should. This can cause the
heart to beat too slowly, too quickly or irregularly.
A pacemaker can treat some of these abnormal
heart rhythms.
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What is a pacemaker?
A pacemaker is a small device that is placed in
the chest to help control abnormal heart rhythms
(arrhythmias). It uses a battery and electronic
circuits connected to the heart by one or more wires
(leads) to prompt the heart to beat at a normal rate.
These leads are passed along a blood vessel to your
heart and the pacemaker box is usually implanted
under the skin in your upper chest. The pacemaker
can monitor your heart and produce electrical
impulses to treat abnormal heart rhythms.
An example of a
leadless pacemaker
Pacemakers are largely used to treat slow heart rhythms (bradycardia), but are
also used to treat some fast heart rhythms that come from the top chambers of
the heart (the atria). One type of pacemaker, the biventricular pacemaker
or cardiac resynchronisation therapy pacemaker, is increasingly being used to
treat patients with heart failure; this is not suitable for all but can be discussed
with your doctor.
Pacemakers may be single (one lead), dual (two leads) or triple (three leads)
chambered and you will be fitted with the device appropriate for your
particular condition.
Recently leadless pacemakers have become available for use in specific patients.
These are very small devices that are implanted directly into the heart and there
are no leads required. Your doctor will know whether this is something that
would be suitable for you.
There are approximately 70,500 pacemakers implanted in the UK every year.
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Why do I need a pacemaker?
There are several different common conditions which cause the heart to beat
abnormally. These are:
Complete or intermittent heart block
Heart block accounts for about 60% of patients who have pacemakers
implanted. This is a condition where the AV node does not transmit the electrical
pulse from the top to the bottom of the heart. It may be complete or partial.
When this happens the heart usually beats very slowly and you may have
symptoms of dizziness or blackouts.
A pacemaker is required to restore a normal heart rate and bypass the 'block'.
This is most commonly due to the conduction system 'wearing out with age',
but can also occur as a congenital (in-born) problem or as the result of a heart
attack, infection, or certain medications.
Sick sinus syndrome
This is a condition where the natural pacemaker does not function properly and
results in your heart going either too slowly or too fast or a combination of both.
An implanted pacemaker is used to support the slow heart rate and medicine is
usually given to control the fast heart rhythms.
Post-catheter ablation
Pacemakers are also used following a procedure called catheter ablation that
involves applying radiofrequency (similar to a microwave) energy to the AV
node in your heart, which destroys the cells in this area. This means that the
heartbeats can no longer travel from the top to the bottom of the heart and
a pacemaker is then used to deliver electrical impulses to the heart. You may
have this procedure if you suffer from arrhythmias such as atrial fibrillation (AF),
atrial flutter, or supraventricular tachycardias. You can read more about the
ablation procedure in the Arrhythmia Alliance booklet: Catheter ablation for
cardiac arrhythmias.
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Heart failure
Some people who experience heart failure (when the
heart does not pump as well as it should) can benefit
from having a particular type of pacemaker, which
is known as a biventricular pacemaker or cardiac
resynchronisation therapy.
If you have heart failure, this therapy may improve some of your symptoms.
However, not all people who experience heart failure will benefit from this
treatment and careful assessment is needed before this type of pacemaker
is implanted.
New leadless pacemaker
A new-style pacemaker is now available, designed to be placed directly in the
heart without the visible surgical pocket, scar and insulated leads required for
conventional pacemakers. The device offers a less invasive approach for patients
compared to traditional pacemaker procedures and is fully retrievable.
Total implant procedure time is around half an hour. Even with miniaturisation,
the device battery is expected to have an average lifespan of more than nine
years at 100% pacing, or more than thirteen years at 50% pacing.
Most patients still require the traditional pacemaker with leads but discuss this
option with your doctor to learn more.
How is the pacemaker implanted?
On the day of your procedure, you will be taken to the cardiac pacing theatre or
catheter lab. Once you are in the pacing theatre, a nurse will check your details
and you will be asked to lie on a trolley or narrow operating table.
The procedure is not usually performed under a general anaesthetic, but you
may be given sedation, which will make you relaxed and sleepy.
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Before the procedure starts, the doctor will clean the skin with some antiseptic
solution and inject some local anaesthetic under the skin just below your
collarbone (usually on the left side as most people are right handed, however
if you are left handed your doctor may be able to implant the device on the
right side).
This will numb the area and allow the doctor to pass a small lead or electrode
through a vein into your heart. You may have one, two or three leads inserted
depending on what type of pacemaker you need. The lead(s) are then connected
to the pacemaker box. This will usually be placed under the skin on your chest
wall. The area will then be closed with dissolvable or non-dissolvable stitches.
If your stitches need to be removed by your GP, practice nurse or district nurse
you will be informed before you leave hospital. The whole procedure should take
approximately 60 to 90 minutes.
Are there any risks associated with the procedure?
There are some small risks associated with having a pacemaker fitted.
Your doctor/specialist nurse will discuss these with you in more detail before
you sign your consent form. The most common risks are:
• A small risk of infection, bleeding and bruising to the pacemaker site.
• A small risk of lead displacement – the pacemaker lead can move
and would then need to be repositioned.
• A small risk of perforation of the lung during the procedure
(a pneumothorax) – this is often detected on the chest x-ray that
is performed following the pacemaker implant and can sometimes
rectify itself without treatment. Very occasionally a small drain may
need to be inserted through your side into your lung (in the space
between your ribs) to allow the punctured lung to re-inflate.
This is a simple procedure and the drain will be removed prior
to your discharge home.
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What happens after the pacemaker
is fitted?
After the procedure, you will be taken back to the ward. You will be asked to
lie in bed for a couple of hours before you can get up, eat and drink. Your heart
rhythm may be monitored for a while to make sure that the pacemaker is doing
its job, so you may be attached to an ECG monitor. As the wound can feel quite
bruised and sore, especially for the first day or two, it is recommended that you
take regular painkillers. It is important that you tell your nurse immediately if
you have any pain or discomfort. You may also be given some antibiotics to take
before and after the procedure to minimise the risk of infection.
The wound should be kept clean and dry until it has fully healed, although it is
fine to have a bath or shower after the first three or four days. Ask your nurse
for a protective dressing so that you can bathe without getting the wound wet.
Report any wound problems to your nurse.
You will probably be allowed to go home the same or the next day provided your
pacemaker is checked, there are no complications and your doctor assesses
it is safe. Your pacemaker will be checked before you go home by a cardiac
physiologist or the specialist nurse. This check may involve the use of a special
programmer that can look at the device settings and make sure the pacemaker
is working properly, or a simple magnet check and an ECG will be sufficient.
This check takes about 15 minutes and can either be done on the ward or in
the pacemaker clinic. You will also have a chest x-ray to check lead positions
and make sure all is well following the implant procedure. Please ask the
physiologist or specialist nurse if you have any questions or worries about
the device.
You will be given a pacemaker identity card which has details of the make and
model of your pacemaker. You should always carry this card with you. If you
require any further medical treatment in the future it is important that you show
this card to the health care professionals treating you.
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Arm movements
Extra tissue will grow around the lead(s) in your heart after a few weeks, which
will prevent the wire(s) moving out of place. Patients should not interfere with
the area of the implant, but follow the instructions given until the first follow up
visit. As a general guide, you should not raise the arm on the same side as the
pacemaker above shoulder height for the first week. For the next two weeks
full, gentle shoulder movement is allowed. After three weeks you can play golf,
tennis etc. Once you have had your first pacemaker clinic check you will be able
to return to normal activity.
Wound site
Your wound site should take about six weeks to fully heal. Try to avoid wearing
tight clothing over the wound until it has healed completely to avoid excess
rubbing over the area.
If you notice any redness, soreness or swelling of the area, or any signs of
bleeding or oozing from the wound, report this immediately to your implanting
centre as these may be a sign of wound infection.
You will probably be able to feel the pacemaker box under your skin as well as
other lumps close by. These are the leads that are attached to the box, curled
up beside the box under the skin. It is extremely important that you don’t try to
move the box or leads, but do let someone at the implant centre know if they
continue to bother you.
Will I feel the treatment from the pacemaker?
The device will be programmed to the best settings for you. This will be done
before you leave hospital, but the settings can be modified during your follow
up appointments in the clinic, as and when necessary.
You should not be aware of the pacemaker working, so if you feel body muscles
twitching you should report it to the implanting centre.
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The pacemaker will not usually stop the heart from speeding up so if you had
fast palpitations before then they may continue. If this occurs the palpitations
are usually treated by medicine.
The pacemaker will be set to enable your own heart to work as much as possible
on its own and will only come in if your heart rhythm slows down to a certain
level or speeds up to a dangerously fast rate. It works 'on demand' and either
'paces' the slow heart or inhibits the fast rhythm.
Will I be able to stop my tablets after I have my
pacemaker implanted?
This will depend on why you had the pacemaker implanted and your cardiologist
will advise you what to do, but one of the bonuses of getting a pacemaker is that
medications can often be stopped.
Safety issues
Can I still drive after I have my pacemaker implanted?
The Driving and Vehicle Licensing Agency (DVLA) have guidelines in relation to
patients who require a pacemaker and whether or not they are safe to drive.
There will be some restrictions, but these will vary depending on why you have
had your pacemaker fitted. It is very important that you discuss this with your
nurse, physiologist or doctor at your pacemaker centre who will explain this in
more detail.
You must inform the DVLA that you have had a pacemaker implanted it is also
strongly recommended that you inform your insurance company.
Can I exercise after I have my pacemaker fitted?
A certain level of exercise is needed to keep your heart healthy. You can take
part in most sports but it is advisable to avoid contact sports to minimise the risk
of damaging your pacemaker.
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Following your initial recovery, it is advised to avoid strenuous activity in the first
four to six weeks after pacemaker implantation but then to partake in regular
healthy exercise.
Please talk to the doctors, nurses or physiologists at your pacemaker clinic if you
have concerns about physical activity.
Is there any equipment that can affect my pacemaker?
Electromagnetic interference will not damage your pacemaker but may
temporarily interfere with its settings whilst you are in contact with it.
Most mechanical and electrical devices that you use in your normal daily
activities will not affect your pacemaker.
Household equipment such as ordinary radios, fridges, cookers, remote
controls, televisions, electric razors, computers and microwaves etc. will not
affect your pacemaker as long as they are in good working order.
If you buy an electrical appliance you may find that the instructions state
'do not use if you have a pacemaker'. This statement is normally put in to
cover the manufacturers and often is not necessarily applicable. It is best to
check with your pacemaker clinic for advice.
If you feel dizzy or experience palpitations whilst using an electrical appliance,
you should move away from the appliance and phone the physiologist,
specialist nurse or doctor at the pacemaker clinic for advice.
Magnets
Do not carry magnets or place a magnet over your chest. Avoid carrying
stereo or hi-fi speakers as they contain strong magnets that can interfere with
your pacemaker.
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Shop doorway security systems
It is advised that you walk through shop doorway
security systems at a normal pace and not to wait
around in this area.
Medical equipment / other hospital treatments
Most equipment used by your hospital or GP surgery
will not cause any problems to your pacemaker.
However it is advised that you let medical and
dental staff know that you have a pacemaker.
Please take your ID card with you whenever you go
to hospital. It may also be useful to contact your
implanting centre for advice before you go into
hospital for any investigations or operations that
are not associated with your pacemaker.
It is safe for you to have x-rays, CT scans and mammograms. You should avoid
magnetic resonance imaging (MRI) machines. Some pacemakers are MRI
conditional which means they have been demonstrated to pose no known
hazards in a specified MRI environment with specified conditions of use. If you
have any concerns, please speak to your pacemaker clinic. Some electrical
nerve and muscle stimulators (TENS units) may cause interference with
pacemakers but this depends on where they are being applied, and, if any of
these treatments are suggested to you then your pacemaker clinic should be
contacted for advice.
Travel
You can safely travel abroad with your pacemaker, but you are advised to show
the security staff your pacemaker identification card. Walk through the metal
detector archway if asked to do so, but the metal casing of the device may set
off the airport security alarm. The detector will not cause any harm to your
pacemaker provided you walk briskly through the arch.
Arc welding
Generally, this should be avoided but can be performed under special
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circumstances. Please ask your pacemaker centre if you need further
information on arc welding.
Mobile phones
Some studies have shown that some mobile phones can affect the pacemaker
if held within six inches of the device. It is therefore recommended that you do
not keep a mobile phone in a coat or shirt pocket over the pacemaker. Keep the
handset more than six inches away from the pacemaker; ideally hold the phone
over the ear on the opposite side to the device.
Pacemaker clinic visits
Your pacemaker should be checked regularly and you will be invited to attend
your pacemaker clinic as required. You will be seen at least once a year and may
be asked to attend more often if necessary. You may also see the consultant
cardiologist or their registrar at your clinic visit.
During each clinic visit, the physiologist or specialist nurse will examine your
pacemaker using a special programmer. This machine will allow them to
examine the settings and the battery life of your device.
Special measurements are also done to assess the state of the leads that
connect the pacemaker to your heart. If your condition has altered, changes
may be made to the pacemaker settings using the special programmer.
All the information is confidentially stored in your records.
Your wound will also be checked and you may have other tests done. Please also
take this opportunity to ask any questions or let the medical team know if you
have any problems or worries.
For working people or people for whom it is very difficult to get to hospital,
most can now have their pacemaker checks done remotely over the internet via
their own home transmitter. The pacemaker activity and your heart rhythm are
then analysed by the clinic in exactly the same manner as when you physically
attend the clinic. More information can be found in our Remote monitoring
patient booklet.
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Monitoring devices
Implantable cardiac monitors
Implantable cardiac monitors (ICM) or implantable
loop recorders (ILR) are small devices that are
implanted under the skin, normally on the upper
left part of the chest. They can monitor the heart
rhythm and record any abnormalities in the rhythm.
This may occur automatically, or be activated by
the patient with an external device. These devices
will not treat any abnormal heart rhythm. They are
used to see if there is a rhythm problem that causes
symptoms e.g. blackouts and/or palpitations. They
may sometimes be used for monitoring too e.g.
after an ablation procedure to see if there is still a
problem. They are normally very simple to implant,
using just a bit of local anaesthetic, and they can last
for two to three years.
They do not have any driving implications or prevent people from doing any
specific activities. If your doctor thinks this is something that would be useful in
your treatment they will discuss it with you.
Portable monitoring devices
More recently, portable monitoring devices have been introduced, about
the size of a smartphone, which keep pacemaker, implantable cardioverter
defibrillator (ICD), and implantable cardiac monitor (ICM) patients connected
to their clinicians remotely, enabling more efficient management of care.
These portable monitoring devices can significantly reduce hospitalisation,
stroke and mortality. However this can only be realised if patients use the
technology consistently.
Speak to your implant centre to discuss the possibility of a portable
monitoring device.
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Changing the pacemaker
Normally a pacemaker battery lasts between six and thirteen years. Your battery
will be checked at every visit to the pacemaker clinic and staff at the clinic will
be able to predict when you need a new pacemaker box and arrange for you to
be admitted at a convenient time for you. Don’t worry, it will not be allowed to
completely run down.
You will need to be admitted to hospital and the procedure is similar to having
your first pacemaker fitted, but it will not usually involve having new leads.
Contacting the pacemaker clinic
Most pacemaker clinics/support services run between 9am and 5pm Monday
to Friday. Ask staff at your implant centre about arrangements to contact them
outside these hours.
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Working together
to improve the
diagnosis, treatment
and quality of life for
all those affected by
arrhythmias
PO Box 3697
Stratford upon Avon
CV37 8YL
+44 (0)1789 867 501
@ [email protected]
www.heartrhythmalliance.org
Registered Charity No. 1107496
© Arrhythmia Alliance
Published 2005
Reviewed August 2016
endorsed by
Please remember that this publication provides
general guidelines only. Individuals should
always discuss their condition with a
healthcare professional.
Acknowledgements: Arrhythmia Alliance would
like to thank all those who helped in the development
of this publication. In particular, thanks are given to
Dr Adam Fitzpatrick, (Consultant Cardiologist and
Electrophysiologist), Jean Maloney, (Arrhythmia Nurse
Specialist), Dr Charlotte D’Souza, (A-A medical writer and
reviewer), Alice Lipson, (Cardiac Physiologist) and Dr Kim
Rajappan (Consultant Cardiologist & Electrophysiologist).
President:
Prof. A John Camm
Patrons:
Prof. Hein J J Wellens
Prof. Silvia G Priori
Mr W B Beaumont OBE
Rt. Hon Tony Blair
HM King Constantine of Greece
Trustees:
Mr Mark Bullock
Mr Nigel Farrell
Dr Adam Fitzpatrick
Prof. Richard Schilling
Founder & Trustee:
Trudie Lobban MBE
If you would like further information or would like to provide feedback please contact Arrhythmia Alliance.